Form BP-A 1053 Inmate Consent/Declination for Hiv Post-exposure Prophylaxis

Form BP-A1053 or the "Inmate Consent/declination For Hiv Post-exposure Prophylaxis" is a form issued by the U.S. DEPARTMENT OF JUSTICE - FEDERAL BUREAU OF PRISONS.

The form was last revised in June 1, 2014 and is available for digital filing. Download an up-to-date fillable Form BP-A1053 in PDF-format down below or look it up on the U.S. DEPARTMENT OF JUSTICE - FEDERAL BUREAU OF PRISONS Forms website.

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BP-A1053
INMATE CONSENT/DECLINATION FOR HIV
U.S. DEPARTMENT OF JUSTICE
JUN 14
POST-EXPOSURE PROPHYLAXIS
FEDERAL BUREAU OF PRISONS
I, [name/reg.no.]
, have been counseled on the
risks of transmission of HIV infection following an exposure incident. I have also been educated on the benefits and the
potential side effects and drug toxicities related to post-exposure prophylaxis with anti-retroviral medications. I understand
that post-exposure prophylaxis is not a guarantee against HIV infection, but has been reported by the Centers for Disease
Control to be effective in reducing HIV transmission following certain exposures.
Consent
I have chosen to take anti-retroviral prophylactic medication.
Inmate Signature
Date
Witness
Date
Declination
I have chosen not to take anti-retroviral prophylactic medication.
Inmate Signature
Date
Witness
Date
PDF
Prescribed by P6190
BP-A1053
INMATE CONSENT/DECLINATION FOR HIV
U.S. DEPARTMENT OF JUSTICE
JUN 14
POST-EXPOSURE PROPHYLAXIS
FEDERAL BUREAU OF PRISONS
I, [name/reg.no.]
, have been counseled on the
risks of transmission of HIV infection following an exposure incident. I have also been educated on the benefits and the
potential side effects and drug toxicities related to post-exposure prophylaxis with anti-retroviral medications. I understand
that post-exposure prophylaxis is not a guarantee against HIV infection, but has been reported by the Centers for Disease
Control to be effective in reducing HIV transmission following certain exposures.
Consent
I have chosen to take anti-retroviral prophylactic medication.
Inmate Signature
Date
Witness
Date
Declination
I have chosen not to take anti-retroviral prophylactic medication.
Inmate Signature
Date
Witness
Date
PDF
Prescribed by P6190

Download Form BP-A 1053 Inmate Consent/Declination for Hiv Post-exposure Prophylaxis

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